Epinephrine linked with more refractory cardiogenic shock after acute MI


Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Study design: A multicenter, prospective, randomized, double-blind study.

Setting: ICUs in nine French hospitals.

Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.

This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.

Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.

Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

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